Practical Illustrations of Typhus Fever, of the Common Continued Fever, and of Inflammatory Diseases, &c. &c

telligible form ; but after all, we believe that the present plan was in some degree the best. Writers of systems have been dealt with very unjustly ; no sooner have some of their leading principles been proved to be untrue, than their, perhaps otherwise, splendid publications have been consigned to the dusty shelf, although the very fact of illustrating a theory presupposes that the writer has collected together a large mass of valuable observations ; and even such might have been the fate of Dr. A's patient and most accurate investigations into the symptoms and treatment of disease. For, as system after system has fallen before the increasing precision of medical reasoning, it would be too sanguine to suppose, that the present explanations of the phenomena of fever, are to leave nothing for future discoverers to perform. It is indeed perfectly apparent, that they are defective in many points, as we shall attempt to shew ; but we feel bound to say, that the work before us, raises it's excellent author to the very highest rank of medical philosophers; conspicu-

creased heat and morbid excitement were present; but on examining the bodies of those dying of fever, in which the skin continued to be, from the first, pale and cold, the energies of the system nearly extinguished, and in which no symptom of excitement had occurred, the author invariably found, that the right side of the heart and the large veins were gorged with black grumous blood, and that not the slightest appearance of arterial fullness existed. Now, if we recollect with our author, that the necessary course of most, or probably all fevers, consists of a cold stage, or stage of oppression; a hot stage, or one of excitement; and a stage of decline or collapse, we shall be led to see, that, as in the stage of oppression, the blood is congested in the venous system; and in the stage of excitement a corresponding accumulation of blood lakes place in the arterial capillaries, the fever is produced by some cause, which, probably by inducing debility of the heart, determines the blood into the venous system; and that the consequent excitement only occurs from the reaction of the constitution, to equalize the deranged circulation, by freeing itself from the load by which it is oppressed. It may be said, indeed, that Cullen's theory de-scribed the hot stage of fever as an effort of nature; but to relieve what ??Not the venous congestion which dissection shows to be present; but a spasm of the extreme arteries which existed no where but in the professor's imagination. Hence, no practical advantage, but the reverse, arose'from this theory ; for as by spasm was meant a state of debility, fevers were considered and treated as diseases of debility throughout. It will be sufficient to say of the inflammatory theorists, that they neglected the stage of oppression altogether, and mistook the effect of fever for the cause which produced it; for from the above simple account of the essential phenomena of fever, it must be evident, that the only necessary and primary part of the disease, falsely called fever, is an oppressed and actually debilitated state of the heart and muscular powers.
What produces this state? and how is it produced ? The nervous system is the part by which the body receives impression from external agents; the body feels the effect of these impressions from the connexions of its nerves; these connexions are either with the muscles or with the heart.
Motion is produced by the connexion of the nerves with the muscular system; whilst, through the medium of the heart, the nervous system gives birth to all the other actions of the body, healthy and diseased. So, if sudden debility of the nervous system be induced, the heart and moving powers will become debilitated in a corresponding degree; and such probably is the primary and only essential state of the body in fever. The cause of fever acting upon the nervous system produces debility; the heart shares in this debility ; and hence the blood is accumulated in the venous system. The debilitating cause may act so violently as to produce death ; if not, accumulation takes place in the veins, and the palpable symptoms of fevers arise in the order above mentioned.
In the volume before us, Dr. A. has, in several places, stated his conviction that the causes of fever act through the medium of the nervous system; but he has not distinctly described the mode in which he conceives the effect to be produced. Content with pointing out the practical differences of appearance which are found in the several stages, and seeing in the great majority of fevers, namely, those in which the. stage of excitement exists, that the practical pathology of the disease refers chiefly to the state of the vascular system, he has been apparently led to neglect the nervous system, by paying too exclusive an attention to the heart and arteries, in his account of the disease; but although he has perhaps expressed himself, occasionally, in an unguardedly strong way, still the neglect is only an apparent one. When once the symptoms have been laid in train by the primary effect upon the nervous system, the disease, for almost all practical purposes, becomes a disease of the vascular system ; all our remedies are directed through that system; in short, as we yet possess no power of appreciating the disorders which take place in the nerves, or perhaps of directly obviating them, when they have taken place, the nervous system becomes a very secondary matter for consideration. The time may come, when our present methods of curing diseases of excitement and inflammation will be entirely changed; when our present imperfect, because indirect, efforts by bleeding and other antiphlogistic means, will be changed for the application of some simple remedy, which, by acting diiectly upon the nervous system, will cure diseases, with a rapidity and a certainty, of which we can at present have no conception. ? The medical philosopher would have been thankful to Dr. A. if he had been more explicit upon this abstruse, yet most interesting part of the inquiry. It is to be hoped, however, that he will hereafter investigate more closely the part which the nervous system performs in the drama Vol. II. No. 7. [Jall. of living actions; and from the rare combination which his mind affords of caution, acuteness, and unbiassed simplicity of object, we tnay perhaps live to see, practically, that the hints we have here thrown out, are founded upon a proper anticipation of what is to happen. Led by these grand distinctive marks between the different states and stages of fever, Dr. A. has divided fevers into the simple, the inflammatory, and the congestive fevers.
In simple fever, the debilitating shock which the system has sustained, by the cause producing the disease, is not sufficient to destroy life; the stage of oppression runs its course, reaction takes place, the blood is gradually transferred from the venous to the arterial system, and the stage of excitement is established. The venous congestion is thus entirely removed; and as the organization is peculiarly perfect, or from some other favourable circumstance, a state of simple increased action is produced, in which there exists no obstruction to the circulation of the blood; and consequently no inflammation. The blood only runs its round of the circulation with increased rapidity; for, with little exception, this circumstance constitutes the whole of that part of the disease. After a time the excitement declines, and the third stage, of collapse, supervenes ; all increased action subsides, and the patient is either left Weak but convalescent, or he dies, probably more from " an exhaustion of the vital principle induced by the preceding excitation," [15] than from disorganization of any part of the body; for we only find that " dissection commonly reveals some remains of an injected state of the capillary arteries, without any effusion of coagulable lymph, adhesion of parts, gangrene or suppuration, which are the results of genuine inflammation." 15.
Such is simple fever. But let the /loss of balance between the arteries and veins be greater; let the venous congestion be more concentrated; let some one part of the body be weakened, or otherwise so disorganized as to offer obstruction in that part to the increased impetus of the arterial circulation ; and inflammation takes place. In this way, an entirely new feature is given to the disease; new sets of symptoms arise, according to the part which is ininflamed; the danger is aggravated, and after death, " effusion of coagulable lymph, adhesions, suppuration, and occasionally some approaches even to gangrene itself," [34] are found in the brain. The effects of inflammation are also found in the medulla spinalis ; or similar disorganiza-1820.] Dr. Armstrong on Typhus Fever. 407 tions occur in the chest or abdomen, according to the peculiar viscera which had suffered, from the inflammation having been particularly seated in them.
In this way, the fever puts on the inflammatory type; or, the first shock, causing the fever, is so violent as nearly to exhaust the energies of life ; or the constitution of the patient is particularly weak, or some other still uninvestigated circumstance is present, so that the reaction does not take place, or is only partially developed, and the heart and circulation are depressed ; the skin is pale and cold, the secretions are suspended, the whole body is oppressed, as with a load, there is much anxiety of the precordia, and either the excitement is but partially developed, or it is entirely wanting. The blood, on being drawn, does not show the buffy coat; and on dissecting the body after death, the large veins in the viscera and the right side of the heart are gorged with black grumous blood. By these signs the congestive fever may be known.
Thus we see, that " in the simple excitive and inflam-izes the state of inflammatory fever as above described.
Such fevers again intermit, when the sub-inflammatorv action, constituting the simple fever, subsides. We do not include the second and more intense state of inflammatory action ; because we believe, that in such cases, the fevers seldom or never take upon themselves again the true intermitting type.* The question of remitting fevers we consider as explicable upon the grounds, that when the excitement, or inflammation connected with them is not very violent, the increased action is occasionally diminished for a time, by the occurrence of perspiration, or of some other excreting, i. e. depleting action. Should the above explanation be deemed satisfactory, the same mode of reasoning will apply to the fevers of children, which are generally tran-Analytical Reviezcs. [Jan.
the accumulation of blood, and perhaps from its being forced into the white vessels; throbbing, from the increased pulsatory pressure, and consequent pain, caused by the action of the heart behind ; and thus the symptoms go on, until the obstruction becomes complete, when gangrene takes place, or the action subsides, and the parts recover their wonted powers, or the secreting vessels take upon themselves a new action; and being assisted by the absorbents, pus is formed. But neither of this last process, nor of what constitutes the primary obstruction, can we offer any explanation. As a further objection to the doctrine, we may say, that we know nothing of the mode in which the causes of fever produce their effects upon the nervous system; nor what those effects are: nothing, or very little, of the peculiarities of that debility of the vascular system which produces congestion of the veins; almost nothing, in fact, of the precise mode in which any one of the phenomena of fever is produced by those which precede it. Again, Dr. A. thinks that there are various fevers in which no previous state of oppression existed; but which are diseases of excitement from the commencement, such as those transitory increases of heat, &c. which follow either the local irritation of a blow, or of a surgical operation, or u the direct application of a stimulus not sufficient at once to inflame any particular part, but to excite the heart into increased action, and the beat of the body beyond the common standard," as i( exposure to an elevated temperature, the use of ardent spirits, wine, or the like, strong mental emotions, rich food, and excessive exercise;" " the local affections which are so apt to supervene being generally to be traced to the increased action of the heart operating on local predispositions, as already explained; these predispositions chiefly varying according to climate, habits, and hereditary structure." 54.
Although the production of fever, in this way, does not appear to be theoretically impossible; yet we confess, we are inclined to believe, that in many, if not in all of the above-mentioned cases, there is a state of oppression and congestion. Such a state evidently follows many blows and operations, when they occasion fever; and we see no reason why the stroke of the sun, improper excess of any kind, or strong mental emotion, should not as readily produce a debilitating effect upon the nervous system, and consequently a stage of oppression, as contagions, marsh effluvia, or vicissitudes of the weather; and if so, may not this stage have been overlooked, even by so accurate an observer as Dr. Armstrong ?
We have still a few more observations to make on the first eause of fever, and the state of the body during that first period, which we consider as the only essential and invariable phenomenon of fever, except, indeed, in the instances above spoken of, if they be really exceptions. We hold, somewhat in contradiction to the words, though, we believe, not to the real opinion of Dr. A. that the primary state of the body in fever, namely, that which in followed by the venous congestion, is a state of real debility. If so, the essence of fever is debility, in contradiction to the letter of Dr. A's expression, that " an extensive observation during a series of years, has convinced me, that the genuine typhus, so far from being of an asthenic character, is, most certainly, an affection of excitement or of congestion, in its first stages, requiring the evacuant plan." [8] Again, It is evidently of the greatest importance to acquire a clear idea of the course of an attack of simple fever. We shall, therefore, extract Dr. A's description of simple typhus entire.. The simple Typhus. " The simple typhus has a first stage of oppression, a second of excitement, and a third of collapse. These successive stages, but more particularly the two last, bear a pretty exact ratio to each other as to degree, but not as to duration. The stage of oppression is usually marked by a variety of symptoms ; among which, the following are mostly conspicuous. Paleness of the face; a peculiar look of dejection and of weariness; some degree of darkness or livor in the integuments surrounding the eves; prostration of strength; diminution of mental energy and of sensibility; cold, creeping sensations on the surface, or short hot and chilly fits alternately; loathing of food; nausea or vomiting; whitish or clammy tongue ; sense of weight or anxiety about the precordia ; occasional sighing and hurried breathing ; aching, heaviness, or giddiness of the head ; coldness of the back, and pains of the loins; a quick, low, struggling pulse, changeable as to frequency, and even irregular as to force. These symptoms are accompanied with feelings of general uneasiness, somewhat resembling those which are experienced after a long journey, or any other great fatigne.
The stage above described sometimes comes on and reveals itself with rapidity; but generally, it is more insidious in its approaches, and occupies from, first to last a period of two or three days; when, after various irregular demonstrations of reaction, it is succeeded by the second stage, or that of excitement, in which there is a complete development of the fever. In subjects who possess constitutional vigour, the tone and velocity of the circulation are now preternaturally increased, and the pulse, accordingly, becomes comparatively expansive, thriily, and somewhat resisting; at least it is widely different from the variable, confined, inelastic pulse of the former stage, and from the uniform free and smoothly-flowing one of health. The cheeks are flushed with a dusky redness; the eyes heavy, and the lips parched. The respiration is quick; the skin almost invariably dry; the heat universally diffused, and steadily above the common point; the tongue foul; the thirst urgent; the uneasiness in the head increased; the sensorium in a highly susceptible state; every symptom, in fine, denoting an excess of excitement. This second stage of the simple typhus, naturally holds a tolerably even tenour for some time. As it proceeds, however, the brain, at intervals, is usually disturbed with reverie or slight delirium, coming on towards evening, when there is an exa-

1820.]
Dr. Armstrong on Typhus Fever. 415 cerbation of the fever; and receding towards morning, when there is a remission; but the prostration of strength, which is at all times very evident, is generally greatest in the period of exacerbations, and the tongue is then drier. During the predominance of the excitement, the bowels have, for the most part, a tendency to constipation. The excretions, as well as secretions, also undergo gradual and material changes, which are evinced by the dark and offensive nature of the faeces, by the peculiar odour of the breath and whole body, and by the morbid appearances exhibited on the tongue, in the fluids formed from the liver, from the kidneys, and from other organs of secretion. " After six or seven days, sooner or later, according to its mildness, or severity, the stage of excitement gradually gives place to that of collapse ; which is first announced by signs of depression in the voluntary powers ; by a certain degree of relaxation in the skin; by a more variable and less concentrated state of the temperature ; and by a notable diminution in the force of the circulation, the pulse being of less volume, softer and undulating. In the mildest cases, the approach of the state of collapse may be viewed as an indication of convalescence. For, although the patient may complain of much general weakness, and sometimes of soreness in the flesh, with flying pains or cramps in the extremities, yet the tongue will be found softer and cleaner, the thirst diminished, the pulse slower, the breathing deeper and less frequent, and the skin of a natural warmth as well as moisture. Besides, the patient will pass much better nights, the functions of the stomach will be in some degree restored, with an evident improvement in the appearance of the feeces, and in general, with a lateritious sediment in the urine.
Whereas, in the more marked instances of this sort of typhus, the supervention of the stage of collapse considerably augments the danger. The prostration of strength then becomes far greater ; the pulse is commonly quicker, and always much weaker ; the tongue fouler, darker, and drier; the voice fainter, and the articulation less distinct.; the respiration short, or feebler, and more anxious. The sensorial functions too are more disordered, and the countenance is more dejected, sunk, and inanimate. Added to these symptoms, the skin feels looser, and appears more shrivelled, while the temperature is no where so intense as in the stage of excitement, but variable in the course of the day, even on the central parts ; and there is an increase of general restlessness, a more perceptible and peculiar foetor about the body, and often an irritating species of cough, which comes as it were in convulsive fits. In this state the patient is disposed to lie on his back. As the peril increases, he not only labours under subsultus tendinum, visual deceptions, low muttering delirium, and difficulty of deglutition, but has also a tendency to slide downwards in the bed, and to draw up the feet frequently towards the body." 10.
The simple typhus generally terminates favourably, but when mortal from neglect or maltreatment, " dissection commonly reveals an injected state of the capillary arte-416 Analytical Reviews. [Jan.
leries, without any effusion of coagulable lymph, adhesion of parts, gangrene or suppuration, which are the results of. genuine inflammation," [15.] but there is probably always some degree of lesion in the structure of some vital organ, though the morbid change may elqde the inquisition of the anatomist.
In this excellent description of simple typhus, how plainly do we recognize the stages of oppression, of excitement and collapse, passing gradually into each other and forming a whole, " the pathology of which is appli*cable to almost all the mildest forms of other fevers; tor, from whatever cause they may originate, or however they may differ in minor respects, the states of the vital organs will be nearly similar in all." [23.] We may see how nearly the state of the circulation in the second stage resembles inflammation, and how easily, by obstruction taking place in the capillary arteries, the simple typhus may lapse into the inflammatory variety of the disease.
" The practitioner, (says our author) should be constantly on his guard from the commencement, and day by day should make the most scrupulous inquiries, that he may be enabled to arrest the very first appearances of inflammation in a vital quarter." 23.
We shall not extract our author's descripticn of the inflammatory typhus, that we may allow ourselves more space to insert his new, and most masterly delineation of the congestive typhus. We consider that the state of inflammation is, in all cases, the effect, and not a cause of fever: The inflammation may indeed begin even at the first period of increased excitement; but then this can only happen from the capillaries of the inflamed parts being predisposed to obstruction from the smallest degree of increased action. " In typhus, the brain or its membranes, the spinal chord or its coverings, the lungs, the pleura, the mucous membrane of the trachea, the stomach, the liver, the peritonaeum, and the small and large intestines are the parts most liable to be attacked by an acute or sub-acute form of inflamma ion." 26. " The brain and its investing membranes being more subject to inflammation in tyr phus, than any other parts of the system." 28. " Whenever, after an attack of typhus, there is a distinctly felt and fixed pain in the head, chest or abdomen, with great quickness of the pulse, dryness of the tongue, anxious breathing, much general oppression, the presence of the acute form of inflammation may be inferred. If there be little or no pain, and the puis-should become Very frequent, the respiration more hurried, the tongue more parched and foul, and the general oppression greater, the approach of the sub-acute form may be apprehended. P .27.

4t7
We must, however, refer to the work itself for the description of typhus when complicated with acute or subacute inflammation of the various vital organs, with the morbid appearances formed after death ; only remarking generally, that the reading of such descriptions should excite in us all, an ardent desire to emulate the unwearied diligence displayed b}' our author in detecting the latent varieties of disease in cases of fever.
General ideas will avail little at the bed-side of a patient, whose life is on the balance, in an attack of acute fever. The season of the year, the constitution, the ten thousand other causes which modify the peculiar nature of individual cases, give birth to a variety in the actual state of the patient, the extent of which can only be expressed by stating the exact number of those individuals who have, at any time, been afflicted with fever; for as no two cases were ever exactly alike, each case, practically considered, becomes a separate disease. It is impossible, therefore, to describe all the states of disease which occur in nature; and thus the lives of our patients hang upon the acuteness, or rather the diligence with which we have made ourselves, practically acquainted, with the precise stale of their organic complaints. Well might Celsus rema?k, that no physician could take care of many patients ; at least of those whose lives are in danger ! And it strikes us, in consequence, that the written descriptions of these varieties are likely to be of much more use to the describer, than to the reader; for it is only by describing the essential peculiarity of each case for himself at the bed-side, that the practitioner can become able to seize upon it on the instant, and snatch his patient from impending destruction. What multitudes have perished from this, too often, reprehensible want of discrimination in medical men ! How often, for instance, have we reprobated physicians for saying, " she is in a consumption, and therefore must die." There are many curable complnints which destroy life under the sweeping influence of the word consumption ; and thus also, on the contrary, in fever, he who can pen such decriptions as are found in Dr. A's volume, will assuredly be likely to save from the grave many of those who would have perished miserably, if under less favourable auspices.
The Congestive Typhus.
" The open forms of fever, in which the heat and arterial action are equally developed, will be found the least dangerous ; ? >vhilst those of an obscure congestive character, in which neither [Jan.
heat nor arterial action is equally developed, are the most perilous and unmanageable. In congestive cases, the local accumulations of blood in the veins obstruct from the beginning the common series of febrile phenomena, and there is, in consequence, either a, total want of morbid heat, or a concentration of it in some particular parts of the body ; whilst others are considerably beneath the natural temperature. It is the entire absence, or the partial presence of excitement, which constitutes the chief external distinction between the severest forms of the congestive typhus, ar. they all coincide in oppressing the functions or in deranging the structure of some important organ, by an almost stagnant accnmulation of blood in some parts of the venous system'" 75. " The attacks of the most dangerous forms of the congestive typhus are generally sudden, and marked by many remarkable symptoms :?An over-powering lassitude ; feebleness of the lower limbs ; deep pain, giddiness, or sense of weight in the encephalon; a dingy pallidness of the face ; anxious breathing ; damp relaxed, or dry withered skin ; and those peculiar conditions of the temperature which have been mentioned above. The pulse is low, struggling and variable ; the stomach irritable ; frequently there is an inability to hold up the head ; and the mind is mojre often affected with dulness, apprehension, or confusion, than with delirium. The whole appearance of the sick impresses the attentive practitioner with the idea, that the system in general, and the brain in particular, are oppressed by some extraordinary load. Both the manner and look of the patients undergo early and great alterations ; sometimes they slowly drawl out their words, or utter them in a hasty, and yet imperfect mode, like people who slightly stammer when embarrassed. They not unfrequently seem as if stunned by a blow, half drunk, or lost in a reverie ; and, at times, have the bewildered aspect of persons suffering under the first shock of an overwhelming misfortune. The eye is occasionally glary and vacant, without redness ; but, at other times, it is heavy, watery, and streaked with blood, as if from intoxication or want of sleep, At the commencement, the pulse is often less altered, as to frequency, than might reasonably be expected, yet, in general, it becomes very rapid towards the close ; the tongue is usually little air tered in the first stage, but in the last it is frequently rough, foul, and brown ; the bowels are mostly very torpid in the beginning, and the stools procured dark and scanty ; whereas, in the advanced stage, the bowels are generally loose, and the stools copious and involuntary. Eructations are not uncommon at all times, and the epigastric region is often much inflated. On account of the general torpor, the secretions are diminished or suppressed ; and, as justly remarked by Dr. Robert Jackson, the skin is often in that peculiar state, that if blisters be applied, they either do not act at all, or so defectively, as to leave an appearance as if the part had been slightly seared by a heated iron. Petechias in general appear earlier in these, than in any othet varieties of typhus; and in the last stage, there ?are sometimes gangrenous spots on the extremities, ] 820.] Dr. Armstrong on Typhus Fever. '419 oozings of blood from the mouth and nostrils, and haemorrhage from the bowels. Analytical Reviews. [Jan.
tremities, the partially concentrated heat of the trunk, and the laxity of the skin. Aural and visual deceptions succeed and force the patient into violent exertions, and every attempt to over-power him by coercion, tends to aggravate the delirium, and sink the strength. I lis tongue grows daily fouler, and his debility greater ; he begins to pick the bed clothes, and at last petechia? and subsultus tendinum appear. About this period, the general turbulence sometimes unexpectedly abates, and he may become so Serene and rational, as to give some hopes that a favourable crisis has really taken place ; but the calm is most frequently deceitful, being soon followed by an universal collapse, in which death occurs, mostly without much struggling. Several cases, nearly answering to the above description, have fallen under my notice, and I have found, that if opportunely and properly encountered, they may generally be subdued ; but that if over looked, or improperly treated in the commencement, they will commonly baffle the best directed measures. " There are yet other forms of congestive typhus, which, after a day or two of lassitude, are usually denoted by chilliness, nausea, short quick breathing, with frequent sighing, unpleasant sensations at the stomach?and also by a white tongue; deprivation of taste, irregularity of bowels, dark bilious excrements, pain and giddiness of the head, an alarmed or confused state of the mind, paleness of the face, dejection and langour of the countenance, inflation of the epigastric region, and great prostration of strength. An imperfect excitement is gradually developed, which rises and falls three or four times in the course of twenty-four hour$. During the slight exacerbations of the fever, the skin is hot and dry in some places, especially about the praecordia; the face flushed; the pulse rapid ; the breathing quickened almost to panting; the eye glossy; the countenance agitated; and the mind solicitous.
These short paroxysms of fever passing away, the skin grows damp and relaxed, the face pale, the pulse less frequent and more undulating, the breathing slower, the eye duller, and the countenance and mind more serene. After some partial efforts of this nature, the excitement is sometimes fully' emerged, the fever may put On a simple or an inflammatory character; but it more often advances, with frequent heats and chills, as an irregular one of congestion, and, if left to itself, most frequently destroys the patient, within the first two weeks of the attack, by cerebral or hepatic derangement, or suddenly suppresses life, by an unexpected engorgement of the brain, or some other vital organ. In such affections, there are occasionally distinct remissions, and likewise apparent translations of local oppression from one part to another.
The remissions are commonly fallacious, and the translations are always to be dreaded, for, independently of the mischief which they may produce in the viscera affected, they denote a loss of the equilibrium and a general disorder in the circulating system, which are not easily corrected. The remarks which have been made, as to the prognosis, in the severer sorts of the congestive fever, are applicable to the forms now described ; except that, in the latter, delirium is sometimes a favourable symptom when it is of the light imaginative kind, and when it occurs with evidences of returning regularity in the circulation and excitement." 81.
These engorgements of the venous system are more frequently found to affect the large vessels about the right side of the heart, the veins of the brain, and liver, and afterwards those of the spleen and lungs. Congestive fevers are seldom ushered in by rigors. Is there a deficiency of electric matter in congestive fever ? Dr. A. says, " In some diseases of general torpor, attended with venous .congestion and a deficiency of animal heat, I have known patients bear an accumulated force of the galvanic fluid with pleasure and advantage ; whereas, in diseases of excitement, attended with an elevation of temperature, the slightest change was painful and prejudical, so that the galvanic fluid became a test, whether the system was in a preternaturally torpid, or excited state." Dr. A. disavows the doctrine of critical days. What may be called critical discharges occur, but not on any particular days. The simple fever, however, has a tendency to decline after a number of days, but this is not the case with the inflammatory or congestive fever.
We now come to the discussion of Dr. Armstrong's treatment of fever; and on this subject we claim our reader's serious attention, for we have repeatedly seen, with the deepest regret, that Dr. A's treatment of fever has been so totally misrepresented, that he has been branded with the name of rash, whilst he is in realitv cautious to the greatest degree ; and has been almost accused ot destroying the patients, whilst, as we have the best means of knowing, he practises, at the Fever Institution, as elsewhere, with a success, which has appeared to us, most worthy of being generally known. Prompt and decisive in the early stages of fever, we know that he seldom loses a patient when placed under his care at the commencement of the disease. In the visceral inflammations too, which mark the middle stages of fever, so accurately does he make the necessary diagnosis, that it is only when his patients are brought into the hospital, in an irremediaable state of collapse, that, we had almost said, any deaths occur; but even in cases like these, by changing the decisive treatment of earlier stages, for a mode of practice more cautious and delicate than can be conceived by those who have not witnessed it, he guides his patients towards health with a skill, which is truly extraordinary. In making this statement, we do not wish to reflect upon Vol. II. No. 7.
[Jan. the practice of other physicians. We speak but what we have seen, and we speak it, because, by statements made without due considejation, much discredit has been thrown upon an excellent mode of practice, to the great detriment of those afflicted.
In continuation of our design of giving a full description of simple fever, we shall dwell upon Dr. A's treatment of Simple typhus. In all cases Dr. A. enjoins absolute rest from the onset. In the stage of oppression, he recommends emetics, followed by a large cathartic injection, and purgatives by the mouth in full doses, to overcome the prevailing torpor of the system. As the surface is cold he enjoins, with these remedies, the warm bath and plentiful internal dilution by means of tepid barley water, or thin gruel with the addition, in very old or debilitated habits, of small portions of weak wines. The apartment not to be below 56 or 60? of Fahrenheit's scale, as inflammations often follow exposure to cold air in the stage of oppression. By such means as these, the circulation is equalized, and the fever is either cut short, or it merges into he stage of excitement.
In this stage the treatment will of course be very different. Dr. Currie's plan by affusion of cold water, will frequently extinguish the fever during the first, second, or third day of the stage of excitement ; but after the fourth day of this stage, it is seldom useful; the tepid affusions or bath (94 or y6?) being, thence forward, better adapted to the state of the constitution. The evening is the most proper time for using the cold affusions; indeed Dr. A. adopts, with some exceptions, the excellent directions given on this subject by Dr. Currie; the water never being used below 60o. With such precautions cold, applied in these ways, has never produced ill effects; in the stage of oppression, however, or of collapse its use may be, and has been fatal. Let it be remembered too, that the cold affusions are so generally efficacious only in the simplest forms of fever. " Seldom less than four or five alvine evacuations should be daily produced during the stage of excitement in tolerably robust subjects" [109]; and to procure this effect, tolerably full doses of medicine must be prescribed. Thus, the intestines will be unloaded, healthy secretions be restored, irregular visceral distributions of blood removed, and the skin be relaxed. Care should be taken to prevent retention of urine.
Wine is prohibited in all cases of the stage of excitement. The diet to consist solely of milk large-J 820.J Dr. Armstrong on Typhus Fever. 423 ]y diluted with water, a little thin arrow root, milk-whey, barley water, or thin gruel. [113] These, with " the admission of fresh cool air, frequent changes of linen, thin bedcoverings, cold sub-acid drinks, quietness, and the abstraction of every extraordinary stimulus," [114]; form the sum of our author's treatment in the stage of excitement.
The stage of collapse is generally, in the milder cases of simple fever, the first approach towards health, and therefore little treatment is required ; light nutriment will generally be all that is necessary. In more severe instances, laxatives are often alone required, unless in neglected cases attended with " great prostration of the natural powers, flushed face, suffused eye, delirium, or some degree of stupor, high breathing, foul tongue, and quick uneven pulse," [115]; "when full doses of brisk purgatives will bring away a load of faeces with evident relief.
When, however, copious, black, bloody stools are passed [Jan.
placed upon the lancet. " In the beginning, or acm^ of the acute-inflammation," let it be used vigorously : " but, if the topical affection has continued for some days, and there are symptoms of a present or an approaching collapse, let not the evidences of any local derangement induce the practitioner to hazard general venesection, as he ?values the life of the patient or his own reputation." [135] This is not the language of rashness, nor is it indiscriminate abuse of the lancet. Local blood-letting, however, is frequently of great use. But the greatest Accuracy is required, to note the exact situation of the patient, and stage of his complaint; and it must not be forgotten, that fevers from the contagion of typhus " will not bear so large and repeated losses of blood, as simple acute inflammatory* such as gastritis, unconnected with contagion." [137]? Faintness, however, should be produced, and this by as small a loss of blood as possible, and therefore the patient should be bled standing, or with the trunk at least erect; " one or two moderate bleedings, followed by purgatives, blisters, leechings, or alteratives," [146] will be generally sufficient in the inflammatory typhus. Fifty-four ounces seem to have formed the largest quantity ever drawn by Dr. A. in inflammatory typhus, until he bled himself to fifty-five ounces, and Mr. Cavel,his pupil, to sixty ounces. Dr. A. speaks very highly of bleeding by leeches; he says that it produces a greater effect upon the heart than the same quantity of blood drawn in any other way would do. Blisters he never uses in the inflammatory'fevers until evacuations have been premised; but they are then very serviceable.
He does not use them also, " at a very late period of the disease, when the exhaustion is excessive, except where there is a tendency to coma." The cold affusions are not so efficacious as in simple typhus; but under proper circumstances, they may be applied after evacuations.
We must content ourselves with these short notices of the general treatment in the inflammatory fever; and must refer to the volume itself, and to the attentive consideration of our readers, for the proper modification of it, so as to meet the peculiarities of the inflammation, as it occurs in various organs.
Treatment of Congestive Typhus. In the congestive variety of typhus, there is much " apparent debility," but still the most efficacious remedies are bleeding, purging, and the warm bath. " It is in the first 1820.] Dr. Armstrong on Typhus Fever. 42> stage only of the highly contagious typhus that genera blood-letting is admissible." Id). The blood will often merely trickle at the commencement, being much darker and thicker than usual; whereas, after some time, it will be of a brighter colour, and flow freely, so as not to be so easily restrained as in ordinary cases. Where the congestion affects the head, the jugular vein or temporal artery should be opened. The pulse generally rises; sometimes, however, the reverse takes place, when the bleeding should not be repeated ; but warm wine and water be given and the warm bath, at 100 degrees, impregnated with salt, be used.
It is necessary to give purgatives in large doses. " In such rapid cases, I have generally given a scruple of calomel at first, repeating much smaller doses, three or four times, on the first day of the attack" [185], " with jalap and very large stimulating enemata; and when the bowels have resisted their united influence, saline purgatives have been added, that no time might be lost" [186].?Patients almost invariably recover with rapidity, when ptyalism is excited ; to favour which, Dr. A. adds to the calomel, after its purgative effect has been established, Small doses of opium, antimony, and camphor. In the very severe cases, a " very powerful impression must be made within the first twenty-four hours, or little good in general can afterwards be effected ; so rapid does the stage of collapse supervene, ?when the visceral congestions are not diminished soon after the attack." 188. " Venesection is certain destruction when the general relaxation has occurred in the congestive typhus." 194.
Stimulants may be moderately exhibited, both during the depletion and afterwards ; blisters also, and after depletion, an antimonial emetic. It is clear to us, that Dr. A. is not himself quite satisfied with this mode of treating the congestive typhus; indeed, he says so in the volume before us.
For ourselves, we confess that we think it defective: if we mistake not, the essence of the congestive state is debility; and the practical desideratum is to restore the lost balance of the circulation. The blood is black and the danger great, because the circulation is nearly at a stand ; under a sudden attack of debility of the heart, that quantity of the blood which was easily circulated during health becomes destructive by its preponderance. We therefore find, with Dr. A. that lessening tfais quantity is often an essential part of the treatment. The bleeding, however, only acts mechanically ; we consider the good of purging Analytical Reviews. [Jan.
to be in like manner mechanical. The warm bath, or rather Nthe hot bath, acts as a direct stimulus; so do blisters; emetics indirectly. According to these principles, may not the conjunction of general stimulants with the above remedies be considered as especially indicated? The case is, however, a very difficult one. The disease we consider to be induced by a sudden loss of vital, or, as we speak, nervous energy, produced by the contagion or other cause of fever. Mow, more than a certain shock to the nervous system must necessarily be fatal; but it appears to us, that in less severe cases, the practical indication is, to stimulate the nervous energy, and assist its efforts to accomplish a reaction, by clearing away, as far as possible, the impediments which obstruct it in its struggle to overcome the load which oppresses it. Amongst other stimuli, Dr.
A. suggests the employment of galvanism or electricity, and we think with great propriety. We hope he will himself put his suggestions to the test of experience.
We have thus given a very slight outline of the principles upon which Dr. A. describes and treats fevers, and our illustrations have been taken from his luminous account of typhus fever in its simple inflammatory and congestive forms.
We have done this, because Dr. A's Essay upon the common continued fever being itself only intended as illustrative of the tract on typhus, it comprehends only the peculiarities of that class of fevers, and therefore is not put into the form of a regular disquisition. But this is really of very little consequence; for, as Dr. A. has very justly remarked, however varied fevers may be, in their external symptoms, their internal pathology is invariably the same. The greatest differences between them, consist chiefly in their degrees of violence ; fevers from contagions, however, vary from common continued fevers in some es-> sential particulars; and therefore it would be very advantageous to be able always to discriminate between them.
The scarlet fever, the small-pox, and measles, indeed, can be easily distinguished ; but the diagnosis between typhus and the common continued fever is often very difficult.
Still, it would seem, that the operation of contagion upon the human body, is, in all cases, very peculiar; and, therefore, we may expect, that future observation will enable us to distinguish the two diseases in all cases. At present, we find that typhus differs from the continued fever, in being more violent in its forms and symptoms; in apparently running a certain course, at |east when once fajrly [Jan. be produced in other than two ways; viz. by contagion, or by the re-occurrence of that peculiar assemblage of natural phenomena from which it first arose.
The subject of fever has been much canvassed lately, from the existence of the present widely-spread epidemic, which has been so destructive in various parts of the united kingdom. From Dr. A's connexion with the fever Institution, he has, of course, had great opportunities of investigating its true nature; and it would appear from his observations, that much of the contrariety of character which has appeared in the description of different practitioners, has arisen from the epidemic having been formed of three distinct descriptions of fever, namely, " typhus, the common continued fever, and a low fever of irritation, arising from filth and defective nutriment.'7 3 J 6.
The following extract from Dr. Cleverly's Annual Report will show under what unfavourable circumstances Drs.
Cleverly and Armstrong have had to combat an epidemic, the common character of which has been extremely severe, during the whole term in which they have practised in the Fever Institution. " The present epidemic commenced in London, about the end of March, 1817, and during twelve or fourteen months the proportion of deaths, in comparison with former years, was certainly very small. In May last, however, the mortality began to be more considerable, and the physician, at that time officiating, reported, that the disease ' seemed to have assumed a character of greater severity, and that the mortality had, in consequence, been very considerable.' And in the report for June, the same physician declared, that the mortality had been unprecedented in any former reports of this Institution ; and this he ascribed, in part, to the increased virulence of the malady, but principally ' to the very advanced stytte of the disease in which many of the patients were admitted, precluding the possibility of affording them effectual relief.' And, in fact, the mortality in June was 1 in 4|, which is greater than at any period (with a single exception) since the Institution has existed. In July (about the middle of which the present physicians were appointed) the ratio was as 1 to about 5-^, and the average ratio for the whole period comprehended in the present report is nearly as 1 to 6. Epidemics have always been observed to differ much from each other in the severity of their characters, and even from themselves, in different periods of their course; so that, in all Institutions, the mortality, in different years, has been found to vary greatly; and, indeed, in the London House of Recovery, it has fluctuated between 1 in 12| and 1 in 3f. But however various this result, we know that the disease was treated by the same physician, in the several instances alluded to, and with the great care and talent by which he is distinguished.

1820.]
Dr. Armstrong on Typhus Fever. 431 " Besides, the mortality in the wards of this Institution cannot be considered as representing, at any time, the general destructiveness of the disease, or the success with which it may be treated in its early stages; for the House has become the receptacle for a very considerable number of the worst cases of typhus in its most advanced stages; and to this cause, certainly, the great mortality is to be attributed. It will appear, on examination, that a very large proportion of the patients has been sent into the House, from under the care of general practitioners, and from the medical officers attached to parishes; and this often not till the disease had assumed its most alarming and desperate character. Patients themselves often evince considerable reluctance to leave their homes, however miserable, and seek relief in an hospital; and, when the first dread of the epidemic is over, they are frequently retained by their relations, till the aspect of the disease has alarmed these for their own safety. Analytical Reviews. [Jan.
contemplating the pure spirit of philosophy, the talent for observing natural phenomena, and the freedom from doctrinal bias, which so distinctly pervade the writings of both. In both of them we find a proneness to theory, but in both an undeviating adherence to facts in practice; in both an almost faulty mildness and forbearance of manner ; but in both, an honest inflexibility in the expression of truth. We prophecy, too, that the fate of each will be the same ; that increasing years will bring to Dr. Armstrong an increase of dignity and comfort, as we believe they did to his predecessor; and that, hereafter, the memory of both will be cherished by posterity, with similar feelings of reverence and rfespect.* * The unexpected length of this article has induced us to print the remainder of this number on a sm^li type, so that we inav cuinpress as much matter as possible within the usual limits. Ed.